Provider Demographics
NPI:1972912566
Name:ALL STAR PEDIATRICS AND SPORTS MEDICINE
Entity type:Organization
Organization Name:ALL STAR PEDIATRICS AND SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RUCHI
Authorized Official - Middle Name:
Authorized Official - Last Name:MEHTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-743-1392
Mailing Address - Street 1:199 BROAD ST
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-2635
Mailing Address - Country:US
Mailing Address - Phone:973-743-1392
Mailing Address - Fax:973-743-3707
Practice Address - Street 1:199 BROAD ST
Practice Address - Street 2:SUITE 1B
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-2635
Practice Address - Country:US
Practice Address - Phone:973-743-1392
Practice Address - Fax:973-743-3707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08474900208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0287326Medicaid